Provider Demographics
NPI:1942300330
Name:TEDESCO, DOMINIC J (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:J
Last Name:TEDESCO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3838 SAN DIMAS ST
Mailing Address - Street 2:SUITE A-100
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2284
Mailing Address - Country:US
Mailing Address - Phone:661-327-8538
Mailing Address - Fax:661-327-5432
Practice Address - Street 1:145 N BRENT ST
Practice Address - Street 2:SUITE 102
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2816
Practice Address - Country:US
Practice Address - Phone:805-643-2375
Practice Address - Fax:805-643-3511
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA45715208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
E51643Medicare UPIN
WA45715CMedicare PIN